A pilot program aims to reduce costs and improve outcomes by visiting patients in the home.
For many of Eric De Jonge's patients, their medical care starts at home. These patients are part of the 10% of the elderly population—the sickest of the sick, with multiple chronic conditions—who account for roughly 60% of the Medicare budget. But De Jonge's patients also are part of the "Medical House Call" program, now 600 patients strong, which has been run for the past decade by 926-licensed-bed Washington (DC) Hospital Center.
De Jonge, director of geriatrics at the hospital center, shares duties with the program's cofounder, George Taler, MD. Their two medical teams, made up of nurse practitioners, social workers, and office staff, crisscross through a section of the nation's capital, providing home-based primary care to patients.
De Jonge and Taler are two of the approximately 4,000 physicians—in addition to nurse practitioners and physician assistants—making home visits part of their practice, according to the American Academy of Home Care Physicians. In 2007, more than 2.2 million house call visits were made, up from 1.5 million a decade earlier. But while that rate is up, it's probably not as high as it could be because of cost.
While it can be argued that the hospital center can make downstream revenue if patients are admitted for care, "I don't think that's a good long-term way to look at it," De Jonge says. Instead, he sees the program as providing patient-centered care for individuals who have trouble leaving their homes for a physician's appointment.
"I see their home: I have great information to take care of them. I talk to their family. I make sure they're taking their medications. We adjust their environment to keep them safe," De Jonge says. Keeping an eye on them can result in reduced hospital emergency department admissions or delayed admissions to a nursing facility.
But, the current fee-for-service program can be discouraging in taking care of this elderly population. The revenue of the program only accounts for 70% of the costs; the other 30% is made up through donations and philanthropy through the hospital center.
On the flip side, the program has been found to reduce the average inpatient length of stay from 8.3 days to 5.9 days. In addition, the house call program keeps patients out of more expensive nursing home care: Nationally, 75% of deaths occur in a hospital or nursing home, but in the House Call program, only 25% of patients were in those settings.
This is why both physicians have backed efforts to include a provision in federal healthcare reform legislation that calls for a pilot project to look at expanding current Medicare coverage for at-home visits. Under the "Independence at Home" proposal, which has received bipartisan support, if the amount of money spent on visits was less than what Medicare expected to spend, then the savings would be given to the provider or organization providing the healthcare.
In Akron, OH, a slightly different way to pay for house calls is being tried with the Summa Health System. Three years ago, a partnership was established among for-profit SummaCare Health Plan, not-for-profit Summa hospitals, and a local foundation to establish a house calls program.
SummaCare pays out on a per member, per month management fee that provides for visits, plus operational support, such as nurse care managers and a consultant pharmacist, according to William Zafirau, MD, medical director of the house calls program.
The program is a different medical model, says Kyle Allen, DO, Summa Health System's chief of the division of geriatric medicine and medical director of postacute and senior services. "It's more focused on care than cure. It has a lot more palliative care principles than strict medicine principles. There's a lot of defining the goals of care with the family and the patient," he says.
"The house calls program for us is really early diagnosis and treatment for patients that have functional or mental impairments that prevent them from getting care or enough care," says Annette Ruby, SummaCare's vice president of health services management. "We want to make sure our patients access the care they need to maintain their health."